Health

Summary

Ms C's second child was stillborn. She said that for a number of weeks prior to the birth she had expressed concern but had not been listened to. She said that staff at the Southern General Hospital failed to respond appropriately when she told them that her waters had broken, and that she was not properly assessed or seen by a doctor. Ms C believed that these failures led to her child's stillbirth.

We took independent advice from a consultant obstetrician. We found that Ms C's temperature had not been monitored as it should have been and that, after two examinations following the rupture of her membranes, she should have been immediately induced. There was also confusion about the responsibility of her care and, thereafter, there were failures in providing her with information. We upheld these complaints.

Although Ms C further complained about the quality of information she received about her child's post mortem, it was considered that reasonable explanations were given, so we did not uphold this part of her complaint.

Recommendations

We recommended that the board:

• make a formal apology for these failures;
• confirm to us that the recommendations made as a consequence of their Significant Clinical Incident Investigation report have since been carried out; and
• recognise this shortcoming in their apology.

Summary

Mr C, an advice worker, complained on behalf of his client (Mr A) who had injured his back at home while breaking wood. Mr A was seen at the practice and complained of pain, pins and needles, and numbness. Mr A asked for an MRI scan (magnetic resonance imaging scan), but was referred for an x-ray which raised no concerns. He continued to experience severe pain and numbness in his legs. Following further consultations at the practice he was advised to attend the local A&E department. He was admitted to hospital and diagnosed with a compressed disc which required surgery.

Mr C complained that the practice had ignored serious red flag symptoms of spinal injury on three occasions and considered that Mr A should have been referred for an MRI scan.

We took independent medical advice from one of our GP advisers, and found that the practice would not have been able to refer directly for an MRI scan. However, the GPs at the practice followed the wrong diagnostic pathway and, as such, failed to identify three red flag symptoms. We concluded that, had the correct pathway been followed, Mr A would have been referred urgently to a specialist.

Recommendations

We recommended that the practice:

• apologise to Mr A for failing to make the appropriate referral during his initial consultations; and
• ensure that all the practitioners involved in reviewing Mr A in this case undertake a review of their practice in relation to management of patients with lower back pain. This should include familiarising themselves with the scope of the relevant Pathway for Management of Lower Back Pain referred to in our decision.

Summary

Mrs C's husband (Mr C) had previously suffered from a brain tumour and had a craniotomy (surgery to remove the tumour). However, his symptoms returned about a year later, and he was diagnosed with another brain tumour. Mr C had another craniotomy, followed by six weeks of radiotherapy. Mr C died a few days after his radiotherapy.

Mrs C raised concerns about the delay in diagnosing Mr C's second tumour, as well as the level of support provided during his radiotherapy treatment. Mrs C was dissatisfied that the GP did not arrange admission to hospital during Mr C's radiotherapy (although she asked about this); that the GP did not arrange district nurses or a care plan for Mr C, or carry out more home visits; and that the GP did not manage Mr C's medication appropriately, or provide reasonable care for his diabetes. Mrs C also raised concerns about the practice's communication. She said the GP never told her or Mr C that his condition was terminal, and refused to answer when she asked how much time Mr C had left to live. She was also unhappy that the GP told her it would be fine to go to work the next day when she asked about this, and Mr C died that day.

The practice apologised to Mrs C for several aspects of their care, including not being more proactive about contacting the hospital on Mrs C's behalf, and for advising that it would be fine for Mrs C to go to work on the day Mr C died. In relation to district nurses, the practice said they had offered this, but Mr C had declined. The practice undertook a significant event analysis, and identified steps to improve their communication about palliative care in the future.

After taking independent medical advice, we upheld one of Mrs C's complaints. Although most aspects of the practice's care and treatment were reasonable, we found the GPs failed to take action in response to a letter from the oncologists suggesting medication to help manage Mr C's aggression, and this was unreasonable. We also found the GP used poor judgment in advising Mrs C that she could go to work the day that Mr C died. However, we accepted that the GP had taken appropriate action in response to Mrs C's complaint, including apologising, reflecting on their practice and carrying out a significant event analysis. We did not uphold Mrs C's complaints about communication, as the prognosis would normally be communicated by the oncologists, and there was also evidence that the GP spoke with Mr and Mrs C about the terminal nature of his illness. We also found it was reasonable for the GP to refuse to give an estimate of how long Mr C had left to live, as the GP could not accurately predict this.

Recommendations

We recommended that the practice:

• bring our findings about the failure to consider the oncologist's suggestion about medication to the attention of the relevant GP for reflection and learning.

Summary

Mr C complained about the board's role in the decision-making that he should be taken to a respite care facility (run by a private care provider) for 24 hours when he had already told them that he did not want to go, and then kept there against his express wishes. Mr C told staff when they arrived at the facility that he did not want to be there, but was persuaded to stay until the following day when his father picked him up. Mr C also raised concerns about an earlier decision by the board to instruct members of staff from the private care provider to covertly befriend him at a radio station where he was volunteering given the effect this had on him, particularly when he saw the staff members at the facility the following year.

We took independent advice from our medical adviser. We found that the board failed to act in line with the relevant legislation, which meant that Mr C's rights were not respected. We also said that it was not reasonable that Mr C was told he was going to the facility on the journey there and that this posed a risk. In relation to Mr C's stay at the facility, we found that there was a responsibility on board staff to ensure that Mr C would be returned to his home if that was his wish. The board had accepted that Mr C told staff when he arrived that he did not want to go in and refused initially to leave the car. We found that most of the healthcare professionals involved were doing everything they could to provide Mr C with treatment, despite his clearly stated wishes to the contrary, believing it was in his best interests. We were critical of the board's actions in relation to the decision that staff should befriend Mr C covertly. In doing so the board failed to respect his autonomy. It was our view that the board failed to act in a reasonable way in respect of Mr C's stay at the facility.

Recommendations

We recommended that the board:

• inform us of how they intend to ensure that decision-making capacity is assessed and clearly documented;
• review their actions in light of our findings and bring our decision to the attention of relevant board staff;
• consider using this decision as a case study to inform current practice in similar circumstances; and
• apologise to Mr C for the failings we found.

Summary

Miss C complained that a paediatric consultant carried out a manual labial separation (separation of the small inner lips around the entrance to the vagina which have become sealed together) on her young daughter at an out-patient clinic without the consent of her and the child's father (Mr B), and without anaesthetic. Miss C said the procedure had caused her daughter to suffer pain and bleeding, ongoing distress, and develop a fear of doctors.

Our investigation included taking independent advice from one of our medical advisers who was of the view that the consultant should have explained and discussed the treatment options with Miss C and Mr B, and had them sign a consent form prior to carrying out the procedure. However, there was no evidence the consultant did so. We were satisfied the consultant failed to obtain informed consent before he carried out the procedure. Our medical adviser also was of the view that undertaking the procedure without a topical anaesthetic (a local anaesthetic whereby a substance is applied directly to the skin to temporarily numb the skin) was unreasonable.

Recommendations

We recommended that the board:

• ensure that the consultant reviews his record-keeping and his practice in relation to the obtaining of informed consent;
• review their policy for the treatment of labial adhesions and consider providing parents with an information leaflet about the procedure and treatment options;
• ensure a consent document is signed by the child's parent or guardian prior to any clinical intervention being carried out;
• apologise to Miss C and Mr B for failing to obtain informed consent;
• ensure that the consultant is made aware of our adviser's comments and reflects on them; and
• apologise to Miss C and Mr B for the performing the procedure on the child without anaesthetic.

Summary

Mr C complained that the board had not been able to evidence or explain the decision to regard his mother-in-law as not suitable for continuing care. There had been protracted correspondence between Mr C and the board, however, he remained of the view that the board could not document their decision.

Our investigation, which included taking independent advice from one of our medical advisers, found that Mr C had been provided with all the available medical records relating to his mother-in-law. These medical records showed that Mr C had been invited to participate in the meetings between medical and social work staff at which they decided to transfer his mother-in-law to social care. Mr C had declined to participate in these and declined to pursue legal guardianship for his mother-in-law. The guidance in force at the time did not require the board to provide Mr C with a written decision or reasons for their decision. We found the evidence showed the family were aware that Mr C's mother-in-law would be transferred to social care and that they understood the decision. There was no evidence they had objected to it at the time.

Summary

Mr C complained that clinical staff at The Royal Hospital for Sick Children (Yorkhill Hospital) had not diagnosed his newly born son's illness. Mr C said he took his son to the hospital three times (he left the second time without being seen due to concerns about cleanliness), but it was only on a family holiday some weeks later in England that his son's pyloric stenosis (tightness of the muscle that connects the stomach to the small bowel, thus causing problems with digesting food and vomiting) was identified.

We considered whether the evidence indicated that clinical staff had acted reasonably. We took independent advice from our medical adviser, who confirmed that pyloric stenosis evolves over time. He said there was no specific guidance that staff should have followed in such a case and, on the basis of the information available at the time, he said it was not unreasonable that staff did not carry out additional investigations for pyloric stenosis. Although we took Mr C's concerns into account, we did not consider that the evidence indicated that the care was unreasonable. We did not uphold this complaint, but we did make one recommendation because a urine test had been misinterpreted by a junior doctor as pointing to an infection.

In terms of Mr C's complaint about the cleanliness of the hospital on his second visit (when he left before being seen), the evidence was limited to the signed cleaning checklists for that day and Mr C's version of events. Although we did not in any way doubt his honesty, and we recognised that the cleaning logs did not absolutely prove the level of cleanliness at any one time, on the basis of the limited paperwork available, we did not uphold this complaint.

Recommendations

We recommended that the board:

• consider reviewing their staff guidance for interpreting urine culture results.

Summary

Mrs C complained about the delay in diagnosing her late husband (Mr C)'s cancer. Mr C suffered intermittent pain over about two years, following a fall. Mrs C said Mr C attended A&E at Glasgow Royal Infirmary on numerous occasions, as well as being seen by colorectal (bowel) and gastroenterology (digestive system) specialists. Mr C's cancer was first diagnosed over two years after his fall, following a scan which showed possible cancer in his liver. Mrs C raised concerns that Mr C should have been given this scan earlier.

The board considered that Mr C received appropriate treatment and investigations. They said they only had records of Mr C attending A&E on two occasions, although Mrs C said he attended numerous times.

After taking independent medical advice from A&E, colorectal and gastroenterology specialists, we upheld Mrs C's complaint. We did not find any evidence that Mr C attended A&E on more than two occasions, and we found that the care and treatment at A&E was mostly reasonable. However, on one occasion the A&E doctor did not specifically record checking whether Mr C was losing weight (which would have been a 'red flag' symptom), and we were critical of this. We found the investigations carried out by the colorectal service were reasonable and timely, and there would have been no reason for them to arrange a scan, based on Mr C's symptoms and the results of other tests and examinations at that time. We also found the gastroenterology clinic arranged appropriate investigations. However, we found there was a delay of several weeks in performing the initial investigations (including the scan) and reviewing the results, which meant that Mr C's care did not meet the Scottish Government's standards for cancer waiting times (HEAT targets).

Recommendations

We recommended that the board:

• issue a written apology to Mrs C for the failings our investigation found;
• raise our findings about the A&E review with the doctor involved for reflection and learning; and
• review their processes for scheduling investigations arising from suspected cancer referrals, taking into account the 62-day HEAT standard.

Summary

Mr C, who was diagnosed with a personality disorder, had some of his medications reduced and stopped soon after entering prison (although he was still on one anti-psychotic medication). He was then transferred to a different prison, where he raised concerns about his medication and asked to be put back on his original medication. Mr C's lawyers also wrote to the prison and his psychiatrist, asking for him to be returned to this medication. Mr C complained about the board's failure to return him to his previous medication.

The board said that Mr C's medication had been assessed on several occasions, including by his psychiatrist from the community (who had prescribed his previous medications), and his medication was prescribed and reviewed as recommended by the psychiatrists.

After taking independent advice from an experienced psychiatrist, we did not uphold Mr C's complaint. We found that Mr C's medication had been appropriately reviewed by psychiatrists, and there was no clinical reason to restart Mr C's previous medications, particularly as several of these medications were addictive and not for long-term use. We also found that Mr C's psychiatrist from the community had reviewed Mr C while he was in a previous prison, and was in agreement with his current medication.

Summary

Mr C complained on behalf of the family of Miss A that the care and treatment she received from the Royal Aberdeen Children's Hospital was unreasonable in so far as it was decided not to provide her with further Intravenous Immunoglobulin Treatment (IVIG, the administration of blood plasma containing antibodies intravenously/into the veins).

Miss A has suffered a rare, slow progressive peripheral nerve dysfunction since she was small. It was not able to diagnose this definitively until 2012. Before that, Miss A had been treated with IVIG on the basis that there was nothing to lose by doing so. Her mother, Mrs A, thought that IVIG made a significant improvement to her condition and wished the treatment to continue. However, the board were of the view that once a diagnosis had been made which indicated Miss A's inability to process vitamin B2, she should be treated with riboflavin.

The complaint was investigated and we took independent advice from a paediatric neurologist. This showed that Miss A's treatment was in accordance with current medical practice and was reasonable; there would be no benefit from her receiving IVIG. Accordingly, we did not uphold Mr C's complaint.